SHOULDER REPAIR
| MANAGEMENT OF FRACTURES OF THE CLAVICLE —W. Benjamin Kibler, MD, Medical Director, Lexington
Clinic Sports Medicine Center, Lexington, KY
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| Treatment goal: restore function
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| Clavicle function: cosmesis of shoulder; link between axial skeleton and arm; controls sternoclavicular and acromioclavicular
(AC) joint arthrokinematics; strut for scapula stabilization; allows normal scapulohumeral rhythm; strut provides
arm support; clavicular 3-D motions—elevation/depression, anterior/posterior, rotation along long axis; clavicle
rotates 40° to 50° on long axis in synchrony with scapula motion as arm elevates; AC joint constrained, 5° to 8° of motion;
rotations associated with arm and scapula motion
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| Restore function: heal fracture (usually not problematic, heals in correct position); maintain strut length, provision
for normal rotational motions; failure due to—nonunion; malunion more important; from shortening, angulation; results
in pain, weakness, decreased shoulder motion, inability to perform overhead activities; maintain rotation of radius
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| Failure to restore function: poor cosmesis; pain at fracture site, especially nonunions; inability to use arm; anterior
coracoid-based shoulder pain, impinged AC joint; complications of nonoperative treatment—weakness, pain
with shoulder straps, pain when sleeping on affected side; scapula problems; third scapula translation; inferior medial
positioning of scapula; muscle weakness from scapula protraction (due to altered position); changes in scapular
orientation—type 1 dyskinesis; posteriorly tilted external rotation; anteriorly tilted internal rotation; shortened
malunion, scapula angulated; loss of clavicular curvature; loss of motion due to lack of long axis rotation
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Evaluation and Treatment
| Acute: degree of comminution; shortening or fragment overlap (>1-cm overlap unacceptable); angulation, consider
computed tomography (CT); scapula position related to clavicular state; consider effects of bracing on length and
scapula positions; early surgical treatment—recommended for patients with vertical butterfly fragment with >1-
cm shortening, anterior/posterior or inferior/superior angulation; “high demand” patient requiring strength
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| Chronic: CT helpful to determine union status, chronic clavicular pain, angulation status, change in long axis of rotation;
other scapula dysfunction symptoms; medial border pain, dyskinesis, arm weakness, lack of forward flexion,
problems with endurance, impingement; nonsurgical treatment options—“figure-of-8” brace provides
scapular retraction, reduces overlap; requires frequent reevaluation; see patient weekly for first 3 wk; S3 brace not
as helpful; surgical treatment—Acumed contoured plate, Rockwood pin; speaker uses straight plate for nonunions
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| DIAGNOSIS AND ARTHROSCOPIC MANAGEMENT OF MULTIDIRECTIONAL AND POSTERIOR
INSTABILITY —Craig D. Morgan, MD, Clinical Professor, University of Pennsylvania School of Medicine, Philadelphia,
and President, The Morgan Kalman Clinic, Wilmington, DE
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| Exclusion plication: take capsule finite distance and sew to intact labrum; must have adequate labrum; suture anchors
for treatment of hypoplastic labrum; performed in zonal fashion; anterior/inferior, posterior/inferior; “fine
tune” (determine if patient is anterior-dominant multidirectional or posterior-dominant multidirectional)
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| Issues of rotator interval: magnitude of sulcus; if sulcus same in external rotation as in neutral, result is wide open
interval; if obliterated, not significant problem; can fine tune depending on magnitude and direction of multidirectional
patient; anterior to posterior plication obliterates volume
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| Examples of findings: anterior-dominant patients have symptoms; no need to examine posterior-dominant patients;
patients with multidirectional instabilities have inferior laxity and redundancy in axillary pouch; usually anterior-
dominant or posterior-dominant (rarely both); if sulcus sign exactly same, patient anterior-dominant; wide open rotator
interval involves capsular and usually tendonous portions of rotator interval; perform open or arthroscopic procedure;
gadolinium magnetic resonance imaging (MRI) arthrography shows increased volume; axillary pouch
hallmark feature; radiates to elbow; beware of multidirectional patient treated as unidirectional traumatic
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| Specialized tools: instruments to pass sutures through capsule into labrum; instruments to tie knots; 16- to 18-gauge
lumen device with flexible nitinol wire loops to pass sutures
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| Operative technique: lateral decubitus position; abducting arm brings capsule up for suturing; better control than
beach-chair position; speaker uses standard anterior and posterior central portals; posterior/inferior portal safe;
speaker uses rasp before suturing zones; full radius shaver or meniscus cutter can cut hole in capsule; expose surface
of labrum; always start inferiorly; first suture at 5- or 7- o’clock position, come up at 6 o’clock; perform hard
part first, rotator interval last; suture materials—controversial; permanent sutures popular, but if placed too
tightly, cannot be altered; speaker prefers polydioxanone (PDS); results same, material does not matter; rotator interval
closure—suture middle glenohumeral ligament to supraglenohumeral ligament; capsular portion rotator closure;
speaker does not include subscapularis (sutures eventually break); sew from middle to superior; use tool that
penetrates capsule and picks up suture; typical appearance of high-volume multidirectional instability (MDI)—
“skybox view” visualizes end zones, complete picture; seen in patient with capsular redundancy or high volume;
anterior dominant—withdraw cannula behind capsule; sew superior to middle glenohumeral ligament; tie sliding
knot with reliability, without looking at it; cut knot blindly (“fail-safe” devices cut tails); close superior to middle;
capsule only, not tendon; use arthroscope to visualize knots; posterior dominant—after plication, use anterior rotator
interval technique; close portal; north/south plication after obliterating recess and axillary pouch; if performing
both anterior rotator interval and posterior dominant, do not tie knot; leave cannula in place; anterior closure (tying
knot blindly at end); patient in sling for 4 wk; active, active-assisted motion, and passive motion exercises; no
sports for 6 mo; teach scapula exercises preoperatively in sling; start exercise immediately after surgery
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| ARTHROSCOPIC MANAGEMENT OF ISOLATED SUBSCAPULARIS TEARS —Jeffrey S. Abrams, MD, Attending
Surgeon, University Medical Center at Princeton, NJ
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| Anatomic considerations: most subscapularis problems not isolated; exist with tears extending beyond subscapularis;
other tendons involved with biceps problem; anatomy well visualized on MRI; subscapularis does not end at
lesser tuberosity; aspects of collagen extend across, creating transverse ligament that holds biceps in place; biceps
stability inherently involved in potential for biceps instability; when biceps instability seen, consider subscapularis
injuries; tears can extend into supraspinatus and subscapularis, involving biceps in middle; tear does not stop at superior
border; subscapularis impingement can occur on anterior glenoid
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| Physical examination for full tear of subscapularis: increased external rotation, passively and actively on injured
side; rare complaints of instability; in young individual, instability event can disrupt subscapularis and portions
of capsule; weakness of internal rotation; signs and tests—Gerber’s positive lift-off test (pulling arm away
from back and releasing it causes arm to fall on back); positive belly-press sign (patient presses both arms against
abdomen, as arm pulled away, elbow collapses to side; cannot maintain internal rotation; recruits other muscles to
keep hand on abdomen); imaging helpful; transverse views on CT or MRI helpful in understanding coracoid anatomy
and whether impression present on subscapularis as result of potential impingement problem
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| Diagnosis confirmed arthroscopically: can visualize superior border of subscapularis; understand biceps subluxation;
dynamic examination—look at subscapularis insertion using scope anteriorly; look at shoulder with arm
in internal and external rotation to determine whether subscapularis moves in conjuction with rotation of humeral
head; suspect preoperative detachment if previous anterior procedures performed; might also see bare lesser tuberosity
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| Surgical procedures: classification—superior border tears, partial- or full-thickness; complete tendon disruption
(footprint of tendon and portions of subscapularis lying on lesser tuberosity); medial retraction of subscapularis after
total avulsion; patient positions—lateral decubitus or beach chair; ability to perform anteriorly, laterally, posteriorly;
freedom to move around shoulder; portals—3 standard plus additional anterior for greater subscapularis
traction against lesser tuberosity; transtendon or partial articular supraspinatus tendon avulsion (PASTA) repair—
anchor into medial aspect of footprint, close delamination with sutures through torn or intact portion to anchor,
bringing subscapularis together as full-thickness tendon to lesser tuberosity footprint; full-thickness tear—place
sutures in tendons to show mobility, putting traction on tissue to be repaired; coracoidplasty (decompression)—
traumatic etiology; open interval window with posterior scope view; release of adhesions and mobilization of tissue
important; at conclusion of operation, test by leaving scope in and rotating humeral head, making sure subscapularis
rotates correctly through movement into external rotation; tendon repair does not return patient to normal
strength; demonstrative weakness present with atrophy and muscle deterioration, unless repair performed acutely;
subscapularis tears—not isolated, often present with anterior/superior cuff tear; fix subscapularis first, then supraspinatus
repair through bursal view; 45% have biceps tendon tears with subluxations; humeral head riding up—
irreversible, irreparable cuff situation, particularly when acromion eroded; challenged with margin convergence;
acromiohumeral distances approaching normal; humeral head goes from superior migration position of 4 mm back
to concentric reduction with cuff closed; reproduce reestablishment of tendon vectors above equator of head
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| DISCUSSION —Drs. Abrams and Kibler
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| Biceps instability: once biceps comes out of groove, difficult to predictably reestablish; speaker has had surgical
successes reestablishing biceps in correct position by anchoring below, recreating pulley system; create subscapularis
repair; biceps tendon pulling subscapularis away from bone, wrapped over top of repair; makes more sense to
cut biceps and perform tenodesis or tenotomy
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| Anchor placement: anchors placed medially on footprint of greater tuberosity; no difference when anchors placed
medially on lesser tuberosity; double row or second lateral anchor placed from bursal (not articular) view; visualization
based on experience; fewer subscapularis tears; slower learning curve; similar to PASTA or Hegel repairs
with scope placed interarticularly; open window of rotator interval looking inside and outside shoulder simultaneously;
with scope in posterior portal, look at lesser tuberosity when facing up; poke scope through rotator interval
looking at bursal side of tendon; arthroscope beneficial for subscapularis repairs; decompressions sometimes
performed for visualization and instrumentation (not always because of biologic friction between soft tissue and
bony prominence)
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| Coracoidplasty: only lateral border of coracoid removed; short arm flexors not released; not manipulating coracoid
arch; most lateralized tip adjacent; be careful not to remove too much (can change lever arm of subscapularis and
create adhesions)
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| Partial-thickness articular-side supraspinatus tear: 50% rule not adhered to; speaker would consider performing
transtendon repair for 35% tendon tear in 35-yr-old workman’s compensation patient; sacrifice trans-tendon
and perform full-thickness if no tendon remains laterally (challenge if bursal side of tendon looks good);
anatomic repair of articular side—leave in place and arthroscopically fix articular side with transtendon or
PASTA repair; can put anchor in medial edge of footprint; lateral aspect intact; move tissue and close down delamination;
if unable to perform procedure, complete tear; consider double row; transverse component delamination
important considerations; transtendon repair good option; apply superior/inferior PDS sutures to achieve delamination;
problem is delamination, loss of rotator cuff dynamics; baseball players tear posterior supraspinatus and infraspinatus
boundaries; most “average” people have articular site tears, anterior third of supraspinatus; surgical vs
nonsurgical treatment depends on where tendon tear occurs; baseball players can have 80% tear in posterior quadrant
and continue to throw ball; think about differences; do not treat all patients same
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| Biggest problem with supraspinatus repairs: when arm internally rotated, anterior corner strained (most difficult
part of supraspinatus repair); paraodoxically, avoiding stretch during early postoperative period can result in
less internal rotation
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| Follow-up: 6- to 12-mo follow-up useful; look for degenerative problems and limited range of motion; duration of
cuff healing longer than expected; 20% strength gain between 1- and 2-yr follow-up
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| Fatty infiltration: arthroscopic repair vs open repair reduces development; improves results
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Suggested Reading
Arrigoni P et al: Calcific tendonitis of the subscapularis tendon causing subcoracoid stenosis and coracoid impingement.
Arthroscopy 22:1139, 2006; Barth JR et al: The bear-hug test: a new and sensitive test for diagnosing
a subscapularis tear. Arthroscopy 22:1076, 2006; Barth JR et al: Arthroscopic capsular release after hemiarthroplasty
of the shoulder for fracture: a new treatment paradigm. Arthroscopy 21:1150, 2005; Beall DP et al: Association
of biceps tendon tears with rotator cuff abnormalities: degree of correlation with tears of the anterior and superior
portions of the rotator cuff. AJR Am J Roentgenol 180:633, 2003; Bennett WF: Arthroscopic bicipital sheath repair:
two-year follow-up with pulley lesions. Arthroscopy 20:964, 2004; Burkhart SS et al: Arthroscopic subscapularis
repair: surgical tips and pearls A to Z. Arthroscopy 22:1014, 2006; Curtis AS et al: The insertional footprint of the
rotator cuff: an anatomic study. Arthroscopy 22:609, 2006; Davidson JF et al: Use of preoperative magnetic resonance
imaging to predict rotator cuff tear pattern and method of repair. Arthroscopy 21:1428, 2005; Gerber C et al:
Lesser tuberosity osteotomy for total shoulder arthroplasty. Surgical technique. J Bone Joint Surg Am 88 Suppl 1 Pt
2:170, 2006; Herold T et al: Indirect MR arthrography of the shoulder: use of abduction and external rotation to detect
full- and partial-thickness tears of the supraspinatus tendon. Radiology 240:152, 2006; Hopkins AR et al: Glenohumeral
kinematics following total shoulder arthroplasty: a finite element investigation. J Orthop Res 25:108,
2007; Kibler WB et al: Evaluation of apparent and absolute supraspinatus strength in patients with shoulder injury
using the scapular retraction test. Am J Sports Med 34:1643, 2006; Lafosse L et al: Anterior and posterior instability
of the long head of the biceps tendon in rotator cuff tears: a new classification based on arthroscopic observations.
Arthroscopy 23:73, 2007; Langenderfer JE et al: Variation in external rotation moment arms among subregions
of supraspinatus, infraspinatus, and teres minor muscles. J Orthop Res 24:1737, 2006; Lo IK, Burkhart SS: Triple
labral lesions: pathology and surgical repair technique-report of seven cases. Arthroscopy 21:186, 2005; Meier SW
et al: Rotator cuff repair: the effect of double-row fixation on three-dimensional repair site. J Shoulder Elbow Surg
15:691, 2006; Nakagawa S et al: Throwing shoulder injury involving the anterior rotator cuff: concealed tears not
as uncommon as previously thought. Arthroscopy 22:1298, 2006; Nord KD, Mauck BM: The new subclavian
portal and modified Neviaser portal for arthroscopic rotator cuff repair Arthroscopy 19:1030, 2003; Smith CD et
al: A biomechanical comparison of single and double-row fixation in arthroscopic rotator cuff repair. J Bone Joint
Surg Am 88:2425, 2006; Waldt S et al: Rotator cuff tears: assessment with MR arthrography in 275 patients with
arthroscopic correlation. Eur Radiol 17:491, 2007; Ward SR et al: Rotator cuff muscle architecture: implications
for glenohumeral stability. Clin Orthop Relat Res 448:157, 2006.
Educational Objectives
| The purpose of this program is to provide the listener with information on management of shoulder repair. After hearing
and assimilating this program, the clinician will be better able to:
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 | 1. Discuss the evaluation, treatment, and management of clavicular fractures.
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| 2. Summarize the surgical techniques used in treating rotator injuries.
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| 3. Evaluate the treatment plan for postsurgical patients.
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| 4. Discuss the tests used in evaluating patients with subscapularis tears.
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| 5. Describe the arthroscopic techniques used in evaluating rotator cuff injuries.
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Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial
relationship with the manufacturer or provider of any commercial product or service discussed. For this issue,
Dr. Abrams has disclosed that he is a consultant for Con-Med, Linvatec, Wright Medical, and Arthrocare. Dr. Kibler
is a consultant for Alignmed.
Acknowledgements
Drs. Kibler, Morgan, and Abrams addressed Shoulder Surgery Controversies 2006, held October 19-21, 2006, in
Newport Beach, CA, and sponsored by the University of California, Irvine, School of Medicine, and The Sports Orthopaedic
Medical Associates, Inc. The Audio-Digest Foundation thanks the speakers, the University of California,
Irvine, School of Medicine, and The Sports Orthopaedic Medical Associates, Inc. for their cooperation in the production
of this program.
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